COVID-19 is changing our lives in ways that we cannot predict, or often imagine, and general practice is no stranger to this. As practices plot their way to a “new normal”, GP pharmacists are hoping that some of the following temporary changes implemented during the pandemic become permanent.
1. More remote working
If you have visited your GP in the past few months, chances are the waiting room was near empty (if the front doors were open at all). The need to socially distance during the pandemic has prompted an increase in telephone and video consultations, with the availability of online consultation tools expanding from around 30% of practices in England in January 2020 to 90% in June 2020, and video consultation capacity increasing from around 30% of practices in January 2020 to 99% in June 2020.
Like many others, practices in Stanwell, Ashford, Staines, Shepperton and Egham (SASSE) primary care network (PCN) in Surrey have expanded their use of technology to limit the need for people to visit the surgery. “Patients with any non-urgent queries are now asked to complete an online questionnaire, which is then sent to a GP, practice nurse or pharmacist for review,” explains Nipa Patel, senior pharmacist for the PCN. “Often, responses to their questions can be texted or emailed back — where previously they may have booked an appointment to get that information.
If we need to see something, we ask patients to send in photos or we use video consultations where appropriate
“If we need to see something, we ask patients to send in photos or we use video consultations where appropriate. We all then have a small number of face-to-face appointments that we can use for anyone who needs to be seen. This way of working allows us to give our attention to the patients who need it most.”
Similar approaches are being used in Lancashire. “I’ve conducted mainly phone consultations since our surgery locked down,” says Katie Smolski, advanced clinical pharmacist for Parkview Surgery, Preston. “As a practice, we have found this way of working far more time-efficient, resulting in reduced stress levels and a better work-life balance, as clinics no longer overrun. I’m not planning on returning to doing the same number of face-to-face clinics that I did before.”
She adds that telephone consultations tend to work better when you already know a patient from previous face-to-face consultations and rapport is already established. “We’ll still need to see some patients in the future, particularly those who are new to the practice and on multiple medicines; those who require a physical examination; and some of our older patients who struggle to hear over the phone.”
In other practices, working remotely and using telephone and video consultations has also solved logistical issues, including an insufficient number of consultation rooms in some surgeries. “To an extent, it’s resolved our properties crisis by allowing more clinicians to practise when clinic rooms are limited,” explains Brendon Jiang, senior pharmacist for Chard, Langport, Ilminster and Crewkerne (CLICK) PCN, Somerset. However, it has revealed the importance of having strong relationships within practices and with other providers in the community, he says.
It’s not impossible to foster relationships when working remotely, but with robust relationships there is already trust, which makes it easier to work collaboratively
“It’s not impossible to foster relationships when working remotely, but with robust relationships there is already trust, which makes it easier to work collaboratively and utilise novel patient pathways and processes.”
Working remotely has also cut down on travel time. “My team find it far easier covering seven rural practices remotely without spending time on the road. It’s an hour-long drive between the two furthest practices, and then there are the care homes,” explains Jiang.
Juliet Bell, senior clinical pharmacist for Bury GP Federation, practice pharmacist and pharmacy adviser for transformation services (which includes intermediate care, rapid response and integrated neighbourhood teams), has found that remote working has made her job more manageable. In recent months she has been involved in several workstreams, including the development of a pharmacy service for care homes and intermediate care, prescribing in end of life care, and development of polypharmacy guidance.
“I’ve been able to work remotely during the pandemic, which has made switching between job roles much more manageable,” she explains. “My IT skills have developed exponentially, embracing video consultation and virtual team meetings to be able to be involved in several working groups, and provide remote supervision and training during the induction of new staff, as well as balancing my own GP practice work.
However, Bell adds that she misses the interaction with her colleagues, “and a quick discussion about a patient is not so easy to do”.
2. Improved team working
Smolski was moved from her usual clinic room in March 2020 as it was designated the practice’s “suspected COVID isolation area”. This relocation, however, proved to be a positive: “I moved to the manager’s office, which was triangulated by the duty doctor’s office and the reception triage phone area. It allows free discussion and workload sharing between myself and the duty doctor. We keep checks on each other throughout the day, sharing prescription workload, and we discuss anything regarding patient care that warrants talking about.
“COVID has brought us together as a practice. We locked down about ten days before official guidance from NHS England due to good direction from the senior partners. The practice secured laptops so we could work from home if things got difficult with childcare. Working hours were allowed to be changed and reviewed every week.”
According to Sue Alldred, head of clinical pharmacy for South and East Leeds GP Group, weekly virtual pharmacy meetings have been instigated in Leeds to bolster team working across the city. “This has allowed pharmacists working in PCNs, general practices, GP confederations, the clinical commissioning group (CCG), and care homes to link in with consultant pharmacists, mental health liaison pharmacists, and those working in the community healthcare team.
[Weekly virtual pharmacy meetings] have allowed us to communicate more effectively and get to know each other better
“It has allowed us to communicate more effectively and get to know each other better. It has also been a forum for sharing COVID-19-related updates around, for example, medicines shortages and monitoring, and has enabled better coordination of our work in care homes.”
The frequency of the meetings has recently been reduced to fortnightly, but the team intends to continue them at least monthly moving forward.
3. Closer working with other sectors
I phoned all of the local pharmacies to check they were OK with the plan
To help those patients advised to shield during the pandemic, GP practices have increased their use of electronic prescribing, which is up from 75% in February 2020 to 86% in April 2020. Patel has also expanded her surgeries’ use of electronic repeat dispensing (batch prescribing). First, though, she consulted with nearby community pharmacies. “I phoned all of the local pharmacies to check they were OK with the plan, and have kept in regular contact throughout to check if any issues have arisen. We also contacted all patients who hadn’t nominated a pharmacy to receive their prescriptions electronically, thus reducing footfall into our surgery. This has been appreciated by the community pharmacies.”
Patel has also remained in regular contact with the local pharmacies to check whether any issues have arisen from her surgeries activating EPS4 (the latest stage in the electronic prescription service [EPS], which allows prescriptions for patients without an EPS nomination to be signed, sent and processed electronically).
Closer working has also been apparent between the hospital and general practice, Patel adds. During the coronavirus pandemic, NHS England advised anticoagulant services to switch patients on warfarin to direct oral anticoagulants (DOACs) to reduce the need for regular blood tests. “The anticoagulation team in the local acute trust has highlighted patients taking warfarin for atrial fibrillation, who might be suitable for a DOAC, to their general practice,” she explains.
Patel also notes that requests for patient-specific advice and guidance from hospital consultants have been answered in “hours rather than days” during recent months — a silver lining, perhaps, to the reduction in hospital activity, with accident and emergency visits more than halving in April 2020 compared with the previous year, and outpatient appointments largely moving online.
4. Greater focus on care homes
In May 2020, NHS England sent a letter to all primary care providers asking them to ramp up the support given to care homes. Part of this included pharmacy and medicines support — where it did not already exist — including facilitating medicines supply, structured medication reviews via telephone or video, supporting reviews of new residents or those recently discharged from hospital, and supporting care homes with medicines queries.
Bell has been involved in implementing the pharmacy response in Bury. This has included the inception of pharmacy teams to support local care homes and an intermediate care facility, and increased collaboration among existing teams.
“Each care home has been aligned to a single GP practice; the PCN pharmacy teams worked closely with the CCG medicines optimisation team to ensure the smooth transfer of patient registration between practices, supported by a medication review,” she explains. “All homes have been given a named pharmacist to contact for queries and a referral process is in place to enable prompt medication review for new patients, those recently discharged from hospital and those newly diagnosed with COVID.
Setting up this new service has been a huge challenge, but very rewarding and welcomed by nursing colleagues
“Setting up this new service has been a huge challenge, but very rewarding and welcomed by nursing colleagues.”
Liz Butterfield, specialist pharmacist at Airedale Telemedicine Hub, believes that history may identify the past few months as a defining moment in the development of pharmacy care home services (see Box). “There has been recognition by the whole clinical system that care home residents will benefit from holistic medication reviews and appropriate deprescribing, and that pharmacists are key to delivering this care.” She believes this has led to the genuine inclusion of pharmacy input into the multidisciplinary care of deteriorating patients.
Butterfield praises organisations such as the Primary Care Pharmacy Association, the Royal Pharmaceutical Society and the Specialist Pharmacy Service for the speed at which training packages have been produced to upskill pharmacists at managing the medicines needs of care home residents.
Box: Adding a pharmacist to a care home telemedicine service
Airedale Telemedicine Hub has provided 24-hour, senior-nurse-led clinical support and video assessment to care homes nationwide for several years. When the coronavirus pandemic struck, doctors in and around Bradford collaborated to add a medical rota to the service, in an attempt to avoid admitting care home residents to hospital. The rota, filled by local consultants and GPs with a special interest in care for older people, was commissioned by Bradford District and Craven CCG to support all local GP surgeries and care homes.
In April 2020, the service began employing a pharmacist, Liz Butterfield, for two days a week — allowing the nurses to call upon her expertise as they see fit. “The nurses might refer to me deteriorating patients, frequent fallers, those who have developed delirium or acute confusion, those with swallowing difficulties or at risk of AKI [acute kidney injury], or anyone else who they deem would benefit from a pharmacist’s input — particularly those for whom polypharmacy is an issue,” explains Butterfield. “I then assess whether any medicines might be contributing to the problem and make recommendations.” She has also joined the daily multidisciplinary meetings that take place via Zoom, providing opportunity for proactive intervention.
Her recommendations are sent to the patient’s GP and practice pharmacist for consideration but, as Butterfield points out, when a recommendation is received from the hub, the GPs realise that the problem has been triaged by a specialist and deemed urgent.
“I’ve really enjoyed the set-up, and it has allowed me to discuss patients informally with GPs and consultants who are working in the hub,” she adds. “While the pharmacist position was initially funded temporarily to respond to COVID, funding has been secured to continue employing a pharmacist in the future.” She believes the service’s model could be replicated regionally.
5. Focus on higher-risk patients
General practice employees know how crucial the month of March 2020 is for finalising a surgery’s performance against quality and outcomes framework (QOF) targets. When the coronavirus pandemic took centre stage earlier this year, and practices had to focus their efforts elsewhere, an accord was reached between the British Medical Association and the Department of Health and Social Care to temporarily relax some requirements and ensure surgeries’ incomes from QOF did not drop compared with the previous year.
Prioritising high-risk patients [rather than all patients with a certain condition] for full reviews makes sense and I really hope QOF reflects this going forward
While general practice has awaited a decision on how QOF will be funded in 2020/2021, some surgeries have seen this as an opportunity to target routine reviews to those most in need. Ziad Suleiman, pharmacist practitioner at Churchdown Surgery, Gloucester, thinks this focus is something that should be considered for the future. “Prioritising high-risk patients [rather than all patients with a certain condition] for full reviews makes sense and I really hope QOF reflects this going forward.”
Suleiman also appreciates the increased use of home blood pressure monitoring by patients at his surgery who want to avoid attendance in person. “This frees capacity for surgery staff and saves patients from assigning time to attend an appointment. It also empowers patients to monitor their own health, and when this is combined with appropriate clinician follow-up, it can be very efficient for patients and the practice.”